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      How to ablate the septo-pulmonary bundle: a case-based review of percutaneous ablation strategies to achieve roof line block

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          Abstract

          Electrical conduction through cardiac muscle fibres separated from the main myocardial wall by layers of interposed adipose tissue are notoriously difficult to target by endocardial ablation alone. They are a recognised important cause for procedural failure due to the difficulties of delivering sufficient energy via the endocardial radiofrequency catheter to reach the outer epicardial layer without risking adverse events of the otherwise thin walled atria. Left atrial ablations for atrial fibrillation (AF) and tachycardia are commonly affected by the presence of several epicardial structures, with the septo-pulmonary bundle (SPB), Bachmann’s bundle, and the ligament of Marshall all posing substantial challenges for endocardial procedures. Delivery of a transmural lesion set is essential for sustained pulmonary vein isolation and for conduction block across linear atrial lines which in turn has been described to translate into a reduced AF/atrial tachycardia recurrence rate. To overcome the limitations of endocardial-only approaches, surgical ablation techniques for epicardial or combined hybrid endo-epicardial ablations have been described to successfully target these connections. Yet, these techniques confer an increase in procedure complexity, duration, cost, and morbidity. Alternatively, coronary venous system ethanol ablation has been successfully employed by sub-selecting the vein of Marshall to facilitate mitral isthmus line block, although this approach is naturally limited to this area by the coronary venous anatomy. Increased awareness of the pathophysiological relevance of these epicardial structures and their intracardiac conduction patterns in the era of high-resolution 3D electro-anatomical mapping technology has allowed greater understanding of their contribution to the persistence of AF as well as failure to achieve transmural block by traditional ablation approaches. This might translate into novel catheter ablation strategies with procedural success rates comparable to surgical ‘cut-and-sew’ techniques. This review aims to give an overview of percutaneous catheter ablation strategies to target the SPB, an important cause of failed block across the roof line and isolation of the left atrial posterior wall and/or the pulmonary veins. Existing and investigational technologies will be discussed and an outlook of future approaches provided.

          Graphical Abstract

          Graphical Abstract

          How to ablate the septo-pulmonary bundle? Examples of electroanatomical activation maps and left atrial CT model with epicardial connections (Septopulmonary Bundle in orange, Bachmann's Bundle in red, Ligament of Marshall in green).

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          Most cited references65

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          Early Rhythm-Control Therapy in Patients with Atrial Fibrillation

          Despite improvements in the management of atrial fibrillation, patients with this condition remain at increased risk for cardiovascular complications. It is unclear whether early rhythm-control therapy can reduce this risk.
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            Approaches to catheter ablation for persistent atrial fibrillation.

            Catheter ablation is less successful for persistent atrial fibrillation than for paroxysmal atrial fibrillation. Guidelines suggest that adjuvant substrate modification in addition to pulmonary-vein isolation is required in persistent atrial fibrillation.
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              Pulsed Field Ablation for Pulmonary Vein Isolation in Atrial Fibrillation

              Catheter ablation of atrial fibrillation using thermal energies such as radiofrequency or cryothermy is associated with indiscriminate tissue destruction. During pulsed field ablation (PFA), subsecond electric fields create microscopic pores in cell membranes-a process called electroporation. Among cell types, cardiomyocytes have among the lowest thresholds to these fields, potentially permitting preferential myocardial ablation.
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                Author and article information

                Contributors
                Journal
                Europace
                Europace
                europace
                Europace
                Oxford University Press (US )
                1099-5129
                1532-2092
                October 2023
                15 September 2023
                15 September 2023
                : 25
                : 10
                : euad283
                Affiliations
                Institute for Cardiovascular Science, University College London , 5 University Street, WC1E 6JF London, UK
                Department of Cardiology, Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Foundation Trust , Eastern Rd, Brighton BN2 5BE, UK
                Department of Cardiology, Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Foundation Trust , Eastern Rd, Brighton BN2 5BE, UK
                Department of Cardiology, Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Foundation Trust , Eastern Rd, Brighton BN2 5BE, UK
                Author notes
                Corresponding author. Tel: +00 44 (0) 20 7679 2000, E-mail address: johanna.tonko.21@ 123456ucl.ac.uk

                John Silberbauer and Ian Mann equal contribution as co-senior authors.

                Conflict of interest: JS and IM have received consultancy fees from Abbott and Biosense Webster.

                Author information
                https://orcid.org/0000-0002-4689-8384
                https://orcid.org/0000-0002-2245-7285
                https://orcid.org/0000-0002-4793-0673
                Article
                euad283
                10.1093/europace/euad283
                10558061
                37713215
                d7d28cf0-d5e1-49e1-9ae4-fec0a6fb7bbd
                © The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License ( https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

                History
                : 27 June 2023
                : 06 September 2023
                Page count
                Pages: 11
                Categories
                Practical EP
                AcademicSubjects/MED00200
                Eurheartj/1
                Eurheartj/3

                Cardiovascular Medicine
                atrial fibrillation,percutaneous catheter ablation,epicardial connections,septo-pulmonary bundle,ablation strategies

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